Tag Archives: Cardiac Arrest

Morton’s Fork 2/2

Kevin navigates the residential streets to St. Closest while I’m in the back with the sergeant tracking respirations and the fire medic helping me by taking vitals. My new patient, who was dead just a few minutes ago, is actually doing pretty well. He’s got a decent blood pressure, reactive pupils, 12-lead is clear, and he’s got some spontaneous movement in the extremities. I decide not to put him on ice (therapeutic hypothermia) based on his increasing level of consciousness and the knowledge that the ED at St. Closest wouldn’t continue with the procedure over the next 24 hours.

We move him over to the bed at the ED and I give a report to the MD and nurses who are going to continue treatment. They seem a little crestfallen as they are surprised by the level of consciousness of the patient. It’s not like anyone is sad to see a resuscitation but it’s so uncommon for someone to go from asystole to having perfect vitals and be sitting upright in a bed and staring at you that they are at little bit of a loss. Unlike in the movies, where they seem to bring people back from asystole all the time, in real life a flatline most often means game over.

I’ll check back in a few minutes but right now I have a mountain of paperwork to do in documenting all of the things we did and how the patient responded. I walk out of the ED towards the rig so I can start typing on my computer.

Two EMTs from the Inter-Facility Transport division are walking in and one of them catches my eye. “Hey, did you have Brian’s dad?”

“No, I had a code-blue with a resuscitation.” I’m just a little proud of myself for pulling off an improbable field save. They look a little bit confused but continue into the ED. I’m walking to the rig when it finally hits me. Fuck ME! The son was Brian!

I didn’t recognize him out of uniform. He’s been working as an EMT in the county forever, long before I got here. He’s a career EMT in the Inter-Facility Transport division so I seldom see him on the streets or at the ED. I’ve only talked to him a few times and I knew he looked familiar – but I just couldn’t place him.

I’m actually shaking as I tap away at the computer to document the call. I’ve never worked up the family member of someone I know, much less pulled them back from the dead. And having pulled off a minor miracle I took him to the one hospital in the county that none of my co-workers would ever want to go to – much less send their recently dead father to. I feel like I let him down, however paradoxical that feeling may be. I just can’t shake the torment in my mind.

Having finished my paperwork I drop it off in the room and see that Brian’s father is sitting up, talking to staff and family, and upon glancing at the monitors I see that every vital sign in well within normal limits. The other son and his wife thank me as I try to get out of the ED. I’m starting to feel like I need to vomit. I need to move on to the next call and shake this out.

Kevin’s waiting for me and he’s also trying to digest the news as I jump in the driver’s seat and put my hand on the key. I look up through the windshield to see Brian sitting on a bench being comforted by his girlfriend, crying tears of grief with his face buried in his hands. Try as I might, I physically can’t start the engine. I have to bring this full circle and talk to Brian even in his grief stricken state. I’m not sure if he’s going to take my head off or thank me but I have to see this to the end and do it right now. I have never felt so bad after saving someone’s life before and I can’t really come to terms with the emotional upheaval that’s ripping me apart.

Brian stands up as he sees me walking towards him and his girlfriend backs off to give us some room. I’m seriously expecting him to punch me in the throat and I know that if he does I’m just going to stand there and take it – I might actually deserve it.

“Brian, man, I’m so sorry, I had to come here, you know I did…” We’re both crying now standing just a foot apart.

“Thank you! You saved him. Thank you so much.” His huge arms envelop me in a tearful hug. Oh, thank god! I don’t need an ambulance…

“No, you saved him. You kept his heart going until we got there. It was all you!”

The emotional turmoil that I attempt to convey in this retelling may be difficult for those outside of EMS to fathom. It may seem strange but even on a successful field save we try to get out of the hospital before the family members arrive. I don’t want praise for a life saved and I definitely don’t want blame for a life lost. Speaking for myself, though I think other first responders feel the same, I must preserve my emotional detachment so I can make the right decision at critical times without hesitation. I know I did the right thing in my transport decision. But in retrospect I’m glad that I didn’t recognize Brian while on-scene. I may have hesitated longer or possibly even gone against my training. I’ll never know what I would have done but I know I’m now better prepared if the situation ever comes up again – and I have no doubt it will. 

That night Brian’s father was transferred to his hospital of choice with no deficits. After being surrounded by family members for two days he coded on the nursing floor and was pronounced dead. Our resuscitation bought him and the family some time together. Sometimes that’s enough – but in this case I wish the outcome was different.

Morton’s Fork 1/2

mor·tons fork

1 : a choice between two equally unpleasant alternatives

2 : also known as; between a rock and a hard place

3 : 1889, in ref. to John Morton  (c.1420-1500), archbishop of Canterbury, who levied forced loans under Henry VII by arguing the obviously rich could afford to pay and the obviously poor were obviously living frugally and thus had savings and could pay, too.

Each player must accept the cards life deals him or her: but once they are in hand, he or she alone must decide how to play the cards in order to win the game. 

~Voltaire

“Damn! This might be a real call…”

We pull up to the house just as the fire engine stops and three firefighters bound out – headed for our rig to grab the house bags. It’s one of those tribal customs that we all follow and no one ever knows when or how it started. If we use our bags in the house we don’t have to restock the fire department’s bags so when we arrive at the same time as fire, they always walk back to our rig and carry our bags into the house as we bring the gurney. But it’s more the haste of their movements that I’m reacting to at the moment. If this call were just the call for the altered seventy year old that my MDT told me it was, they wouldn’t be moving so fast. I’m thinking there might be a little more to this than my dispatcher led me to believe.

Kevin and I walk up to the front door with our military EMT ride-along in tow. Standing in the small foyer of the house I see the fire medic bent over and feeling for a carotid pulse of a man who is laying in the back hallway. “Yeah, it’s code-blue – bystander CPR was in progress until just a second ago.” Okay, cardiac arrest – looks like we’re working a code today. It’s my call so I ask them to move my new patient to the foyer so we have some room to work. As they carry the very large lifeless body my direction, I open up the drug box and set up the monitor. I’m going to work everything here in the foyer and see where we go from there.

Working a code is something like the altered reality of visiting the Twilight Zone for a few minutes. I have an omni-present yet tunnel visioned perception of the world where I’m acutely aware of minute detail yet still processing and interacting with my peripheral surroundings. While attaching the monitor I’m handing a BVM (bag valve mask) and NPA (nasal pharyngeal airway) to the military ride-along. For now I’ll keep him on the head to manage the airway and breathing for the patient. Later on I’ll switch him to compressions, but I want the experienced firefighter doing the first few – all too important – rounds while I figure out IV access, spin up some drugs, and evaluate the monitor for any shockable rhythms. With my mind prioritizing all of these tasks I delegate to the crew and somehow manage to listen to some random family member standing behind me, who’s telling me that he saw his father collapse and did CPR until we arrived.

Kevin thinks he has a good shot at a vein and goes for it while I have them stop CPR so I can feel for a carotid pulse and check out the monitor – no pulse and the flat line of asystole on the monitor. “Resume CPR.” I hand the OPA (oral pharyngeal airway) to the camouflaged sergeant who’s breathing for the patient right now. There was a day when I would have immediately laid down at the patient’s head and intubated while holding CPR to get that all so important tube, but the recent data seems to de-emphasize the intubation so I’ll cross that bridge in a few minutes when I figure out where this code is going. Besides, I wanted the sergeant to get the feel of inserting the nasal and oral airway adjuncts as they will be the primary ones that he uses in the future and it’s the right thing to do for the patient at this stage in a code.

Kevin looks up in frustration. “I didn’t get it, the vein collapsed on me.” After only five minutes of down-time, even with CPR, the blood volume in the vein has reduced making it deceptively hard to hit with a needle.

“No worries, I’ll drill him.” I pull out the bone drill and sterilize my target area on the lower leg where I’ll be using the electric drill to drive a metal catheter into the bone marrow and give us access to my new patient’s veinous system for drug administration.

While I drill, Kevin cuts off clothing, the rhythmic bounce of CPR rocks the lifeless body beneath me, and the army sergeant squeezes the bag every few seconds, providing life-giving oxygen. I can still hear the man’s son in my ear talking about how his father wasn’t feeling too well today and how he has a lot of medical problems – surreal Twilight Zone.

There’s too much fat on the leg and my drill never even reaches the bone. I stifle the automatic profanity that comes to mind – family members are standing over us and they don’t need to see frustration on our faces as we attempt a resuscitation. Reaching back into the drug box I pull out the bariatric bone needle and attach it to the drill. While I drill his leg a second time I explain what we’re doing to the son who’s floating over my shoulder. With the larger needle secured in the bone I attach the bag of fluids and inflate the pressure bag to force saline into the veinous system. I turn around to hand the bag to the son – I want to give him a job so he feels like he’s doing something. He did a good job by providing CPR until we arrived so I want to include him in the process. Looking up at him for the first time I’m momentarily stunned. Damn! He looks familiar but I can’t place him. I’m fairly certain I’ve never been in this house before. Whatever; work the code.

The second round of CPR is done and I do a pulse check while staring at the flat line of asystole on the monitor again. “Resume CPR, first Epi going on-board.” I inject the drug into the line and pump up the pressure bag a few times to push it into the system. I help Kevin in cutting off clothing and spin up the next drug so I’m ready to inject it at the next break in CPR. The firefighter who’s been doing compressions sits back on his haunches, after his latest two minute cycle, as I put two fingers to the patient’s neck. I’ll be damned! That’s a faint pulse. I look over at Kevin, “Confirm that pulse for me.” As I put fingers into the femoral artery and Kevin feels at the neck. A quick glance at the monitor shows a string of perfect complexes marching across the screen. Kevin and I lock eyes and simultaneously nod to each other: confirmed! The sergeant looks up at me, “He’s breathing by himself!”

Looking at the sergeant, “Track him with assisted breathing but don’t force it.” To the other two firefighters, sweat pouring off of my very competent CPR go-to guy, “Let’s get a board and some straps in case we have to resume and let’s get transporting. I’ll be going Code-3 to St. Closest.”

The voice of protesting anguish comes from behind me as the son is in tears. “Oh come on man, anywhere but there, don’t take him to that death trap!!” Okay this guy’s face is really starting to bug me, I know I’ve seen him before, but I can’t place it. And he knows our system because that ED is known for its less than stellar performance.

“Look, he’s got a pulse and I can’t risk losing it by driving too far. St. Closest is less than a mile away and I can’t bypass it by four miles – doing Code-3 – to get to Hilltop. You’ve got to believe me – it’s the only option!” I actually considered it for just a half a second but if I lost pulses during transport I will have put this patient in serious jeopardy and I’d have a lot of explaining to do to my medical director. I just can’t risk it.

The son is distraught but he’s not going to go toe to toe with me on the subject. I feel a little bad for forcing the issue against his wishes but I’ve got a dozen other things to do right now that take precedence so we carry on with the transport.